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| Public Act 097-1006
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| HB5548 Enrolled | LRB097 20017 DRJ 65326 b |
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AN ACT concerning regulation.
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Be it enacted by the People of the State of Illinois,
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represented in the General Assembly:
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Section 5. The Hospital Licensing Act is amended by |
changing Section 10.4 as follows:
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(210 ILCS 85/10.4) (from Ch. 111 1/2, par. 151.4)
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Sec. 10.4. Medical staff privileges.
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(a) Any hospital licensed under this Act or any hospital |
organized under the
University of Illinois Hospital Act shall, |
prior to the granting of any medical
staff privileges to an |
applicant, or renewing a current medical staff member's
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privileges, request of the Director of Professional Regulation |
information
concerning the licensure status and any |
disciplinary action taken against the
applicant's or medical |
staff member's license, except: (1) for medical personnel who
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enter a hospital to obtain organs and tissues for transplant |
from a donor in accordance with the Illinois Anatomical Gift |
Act; or (2) for medical personnel who have been granted |
disaster privileges pursuant to the procedures and |
requirements established by rules adopted by the Department. |
Any hospital and any employees of the hospital or others |
involved in granting privileges who, in good faith, grant |
disaster privileges pursuant to this Section to respond to an |
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emergency shall not, as a result of their acts or omissions, be |
liable for civil damages for granting or denying disaster |
privileges except in the event of willful and wanton |
misconduct, as that term is defined in Section 10.2 of this |
Act. Individuals granted privileges who provide care in an |
emergency situation, in good faith and without direct |
compensation, shall not, as a result of their acts or |
omissions, except for acts or omissions involving willful and |
wanton misconduct, as that term is defined in Section 10.2 of |
this Act, on the part of the person, be liable for civil |
damages. The Director of
Professional Regulation shall |
transmit, in writing and in a timely fashion,
such information |
regarding the license of the applicant or the medical staff
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member, including the record of imposition of any periods of
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supervision or monitoring as a result of alcohol or
substance |
abuse, as provided by Section 23 of the Medical
Practice Act of |
1987, and such information as may have been
submitted to the |
Department indicating that the application
or medical staff |
member has been denied, or has surrendered,
medical staff |
privileges at a hospital licensed under this
Act, or any |
equivalent facility in another state or
territory of the United |
States. The Director of Professional Regulation
shall define by |
rule the period for timely response to such requests.
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No transmittal of information by the Director of |
Professional Regulation,
under this Section shall be to other |
than the president, chief
operating officer, chief |
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administrative officer, or chief of
the medical staff of a |
hospital licensed under this Act, a
hospital organized under |
the University of Illinois Hospital Act, or a hospital
operated |
by the United States, or any of its instrumentalities. The
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information so transmitted shall be afforded the same status
as |
is information concerning medical studies by Part 21 of Article |
VIII of the
Code of Civil Procedure, as now or hereafter |
amended.
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(b) All hospitals licensed under this Act, except county |
hospitals as
defined in subsection (c) of Section 15-1 of the |
Illinois Public Aid Code,
shall comply with, and the medical |
staff bylaws of these hospitals shall
include rules consistent |
with, the provisions of this Section in granting,
limiting, |
renewing, or denying medical staff membership and
clinical |
staff privileges. Hospitals that require medical staff members |
to
possess
faculty status with a specific institution of higher |
education are not required
to comply with subsection (1) below |
when the physician does not possess faculty
status.
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(1) Minimum procedures for
pre-applicants and |
applicants for medical staff
membership shall include the |
following:
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(A) Written procedures relating to the acceptance |
and processing of
pre-applicants or applicants for |
medical staff membership, which should be
contained in
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medical staff bylaws.
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(B) Written procedures to be followed in |
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determining
a pre-applicant's or
an applicant's
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qualifications for being granted medical staff |
membership and privileges.
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(C) Written criteria to be followed in evaluating
a |
pre-applicant's or
an applicant's
qualifications.
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(D) An evaluation of
a pre-applicant's or
an |
applicant's current health status and current
license |
status in Illinois.
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(E) A written response to each
pre-applicant or
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applicant that explains the reason or
reasons for any |
adverse decision (including all reasons based in whole |
or
in part on the applicant's medical qualifications or |
any other basis,
including economic factors).
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(2) Minimum procedures with respect to medical staff |
and clinical
privilege determinations concerning current |
members of the medical staff shall
include the following:
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(A) A written notice of an adverse decision.
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(B) An explanation of the reasons for an adverse |
decision including all
reasons based on the quality of |
medical care or any other basis, including
economic |
factors.
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(C) A statement of the medical staff member's right |
to request a fair
hearing on the adverse decision |
before a hearing panel whose membership is
mutually |
agreed upon by the medical staff and the hospital |
governing board. The
hearing panel shall have |
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independent authority to recommend action to the
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hospital governing board. Upon the request of the |
medical staff member or the
hospital governing board, |
the hearing panel shall make findings concerning the
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nature of each basis for any adverse decision |
recommended to and accepted by
the hospital governing |
board.
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(i) Nothing in this subparagraph (C) limits a |
hospital's or medical
staff's right to summarily |
suspend, without a prior hearing, a person's |
medical
staff membership or clinical privileges if |
the continuation of practice of a
medical staff |
member constitutes an immediate danger to the |
public, including
patients, visitors, and hospital |
employees and staff. In the event that a hospital |
or the medical staff imposes a summary suspension, |
the Medical Executive Committee, or other |
comparable governance committee of the medical |
staff as specified in the bylaws, must meet as soon |
as is reasonably possible to review the suspension |
and to recommend whether it should be affirmed, |
lifted, expunged, or modified if the suspended |
physician requests such review. A summary |
suspension may not be implemented unless there is |
actual documentation or other reliable information |
that an immediate danger exists. This |
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documentation or information must be available at |
the time the summary suspension decision is made |
and when the decision is reviewed by the Medical |
Executive Committee. If the Medical Executive |
Committee recommends that the summary suspension |
should be lifted, expunged, or modified, this |
recommendation must be reviewed and considered by |
the hospital governing board, or a committee of the |
board, on an expedited basis. Nothing in this |
subparagraph (C) shall affect the requirement that |
any requested hearing must be commenced within 15 |
days after the summary suspension and completed |
without delay unless otherwise agreed to by the |
parties. A fair hearing shall be
commenced within |
15 days after the suspension and completed without |
delay, except that when the medical staff member's |
license to practice has been suspended or revoked |
by the State's licensing authority, no hearing |
shall be necessary.
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(ii) Nothing in this subparagraph (C) limits a |
medical staff's right
to permit, in the medical |
staff bylaws, summary suspension of membership or
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clinical privileges in designated administrative |
circumstances as specifically
approved by the |
medical staff. This bylaw provision must |
specifically describe
both the administrative |
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circumstance that can result in a summary |
suspension
and the length of the summary |
suspension. The opportunity for a fair hearing is
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required for any administrative summary |
suspension. Any requested hearing must
be |
commenced within 15 days after the summary |
suspension and completed without
delay. Adverse |
decisions other than suspension or other |
restrictions on the
treatment or admission of |
patients may be imposed summarily and without a
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hearing under designated administrative |
circumstances as specifically provided
for in the |
medical staff bylaws as approved by the medical |
staff.
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(iii) If a hospital exercises its option to |
enter into an exclusive
contract and that contract |
results in the total or partial termination or
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reduction of medical staff membership or clinical |
privileges of a current
medical staff member, the |
hospital shall provide the affected medical staff
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member 60 days prior notice of the effect on his or |
her medical staff
membership or privileges. An |
affected medical staff member desiring a hearing
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under subparagraph (C) of this paragraph (2) must |
request the hearing within 14
days after the date |
he or she is so notified. The requested hearing |
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shall be
commenced and completed (with a report and |
recommendation to the affected
medical staff |
member, hospital governing board, and medical |
staff) within 30
days after the date of the medical |
staff member's request. If agreed upon by
both the |
medical staff and the hospital governing board, |
the medical staff
bylaws may provide for longer |
time periods.
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(C-5) All peer review used for the purpose of |
credentialing, privileging, disciplinary action, or |
other recommendations affecting medical staff |
membership or exercise of clinical privileges, whether |
relying in whole or in part on internal or external |
reviews, shall be conducted in accordance with the |
medical staff bylaws and applicable rules, |
regulations, or policies of the medical staff. If |
external review is obtained, any adverse report |
utilized shall be in writing and shall be made part of |
the internal peer review process under the bylaws. The |
report shall also be shared with a medical staff peer |
review committee and the individual under review. If |
the medical staff peer review committee or the |
individual under review prepares a written response to |
the report of the external peer review within 30 days |
after receiving such report, the governing board shall |
consider the response prior to the implementation of |
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any final actions by the governing board which may |
affect the individual's medical staff membership or |
clinical privileges. Any peer review that involves |
willful or wanton misconduct shall be subject to civil |
damages as provided for under Section 10.2 of this Act.
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(D) A statement of the member's right to inspect |
all pertinent
information in the hospital's possession |
with respect to the decision.
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(E) A statement of the member's right to present |
witnesses and other
evidence at the hearing on the |
decision.
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(E-5) The right to be represented by a personal |
attorney.
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(F) A written notice and written explanation of the |
decision resulting
from the hearing.
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(F-5) A written notice of a final adverse decision |
by a hospital
governing board.
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(G) Notice given 15 days before implementation of |
an adverse medical
staff membership or clinical |
privileges decision based substantially on
economic |
factors. This notice shall be given after the medical |
staff member
exhausts all applicable procedures under |
this Section, including item (iii) of
subparagraph (C) |
of this paragraph (2), and under the medical staff |
bylaws in
order to allow sufficient time for the |
orderly provision of patient care.
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(H) Nothing in this paragraph (2) of this |
subsection (b) limits a
medical staff member's right to |
waive, in writing, the rights provided in
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subparagraphs (A) through (G) of this paragraph (2) of |
this subsection (b) upon
being granted the written |
exclusive right to provide particular services at a
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hospital, either individually or as a member of a |
group. If an exclusive
contract is signed by a |
representative of a group of physicians, a waiver
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contained in the contract shall apply to all members of |
the group unless stated
otherwise in the contract.
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(3) Every adverse medical staff membership and |
clinical privilege decision
based substantially on |
economic factors shall be reported to the Hospital
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Licensing Board before the decision takes effect. These |
reports shall not be
disclosed in any form that reveals the |
identity of any hospital or physician.
These reports shall |
be utilized to study the effects that hospital medical
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staff membership and clinical privilege decisions based |
upon economic factors
have on access to care and the |
availability of physician services. The
Hospital Licensing |
Board shall submit an initial study to the Governor and the
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General Assembly by January 1, 1996, and subsequent reports |
shall be submitted
periodically thereafter.
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(4) As used in this Section:
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"Adverse decision" means a decision reducing, |
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restricting, suspending,
revoking, denying, or not |
renewing medical staff membership or clinical
privileges.
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"Economic factor" means any information or reasons for |
decisions unrelated
to quality of care or professional |
competency.
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"Pre-applicant" means a physician licensed to practice |
medicine in all
its
branches who requests an application |
for medical staff membership or
privileges.
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"Privilege" means permission to provide
medical or |
other patient care services and permission to use hospital
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resources, including equipment, facilities and personnel |
that are necessary to
effectively provide medical or other |
patient care services. This definition
shall not be |
construed to
require a hospital to acquire additional |
equipment, facilities, or personnel to
accommodate the |
granting of privileges.
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(5) Any amendment to medical staff bylaws required |
because of
this amendatory Act of the 91st General Assembly |
shall be adopted on or
before July 1, 2001.
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(c) All hospitals shall consult with the medical staff |
prior to closing
membership in the entire or any portion of the |
medical staff or a department.
If
the hospital closes |
membership in the medical staff, any portion of the medical
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staff, or the department over the objections of the medical |
staff, then the
hospital
shall provide a detailed written |
explanation for the decision to the medical
staff
10 days prior |
